PROJECT SUMMARY African-American (AA) women living in the Deep South are 10 times more likely to be infected with HIV than white women. Traditional HIV prevention methods, including STI/HIV education, comprehensive behavioral interventions, and provision of condoms have rendered minimal success in this population. HIV pre-exposure prophylaxis (PrEP) has become a promising biomedical prevention tool, with over 90% efficacy as shown in numerous trials. PrEP has the potential to curb incident HIV infection among at-risk women; however, biomedical HIV prevention work in the US has generally focused on men who have sex with men, often leaving women (particularly women of racial/ethnic minority status) underserved, and a disparity with respect to HIV infection inadequately addressed. Implementation science projects are urgently needed to evaluate and overcome barriers to PrEP awareness, uptake, adherence, and persistence in this population. The objective of this application is to increase PrEP uptake among AA women at-risk for HIV-infection in the rural South, specifically those seeking care at Federally Qualified Healthcare Centers (FQHC) in rural Alabama. We will use a mixed-methods approach to adapt and pilot test a patient-provider communication tool from the CDC PrEP toolkit that focuses on the first three steps of the PrEP cascade (e.g., recognizing HIV risk, identifying as a PrEP candidate, and interested in PrEP) to increase PrEP uptake via referrals to local PrEP clinics. Specifically, we propose: (1) to explore the HIV risk perceptions of AA women with recent PrEP use (N=15-25), AA women who are candidates for PrEP (N=15-25), and providers (N=20) and identify preferences around patient-provider communication about HIV risk and PrEP services that address the needs of AA women; (2A) To systematically adapt a patient-provider communication tool to increase PrEP uptake at two FQHCs in rural Alabama, using an iterative implementation process; and (2B). To assess the feasibility, acceptability, and preliminary impact of the patient-provider communication intervention on PrEP uptake among AA women and their providers in a pilot pre-/post-intervention design (N=250). As part of aim 2B), we will also systematically document and evaluate reasons for declining a PrEP referral, reasons for incomplete referrals, reasons for failing to initiate PrEP after a successful referral, and ongoing PrEP use at 3/6 months post PrEP initiation among our sample. The proposed work will significantly contribute to our understanding of factors impacting PrEP uptake and use among AA women at high-risk for HIV-infection, particularly in underserved, rural areas in the Deep South that are increasingly impacted by the HIV epidemic and have worse health outcomes relative to other areas in the US. The results of this work will also directly contribute to a full-scale, R01-level cluster randomized implementation trial in which we will measure the effectiveness and cost associated with a PrEP services delivery intervention serving AA women at-risk for HIV-infection in primary care and reproductive health centers in rural areas of the Deep South.